Role of actor networks in primary health care implementation in low- and middle-income countries: a scoping review

Figures & data

Figure 1. Flow diagram of study selection process.

Table 1. Overview of the included papers.

Authors (Year)	Study title	Country	Method/Study design	Study Population
Assegaai & Schneider (2019)	The supervisory relationships of community health workers in primary health care: social network analysis of ward- based outreach teams in Ngaka Modiri Molema District, South Africa	South Africa	Cross-sectional study design with quantitative social network analysis (SNA) approach	Community Health Workers (CHWs), ward-based outreach team (WBOT), PHC facility managers and local area managers
Chami, Ahnert, Voors, & Kontoleon, (2014)	Social Network Analysis Predicts Health Behaviours and Self-Reported Health in African Villages	Liberia	Cross-sectional study design with quantitative household survey SNA approach	Households in highly remote, post-conflict villages in Liberia
Francetic, Tediosi, & Kuwawenaruwa (2020)	A network analysis of patient referrals in two district health systems in Tanzania	Tanzania	Cross-sectional study design with quantitative facility-based SNA approach	Public health facilities in the districts
Hall et al. (2019)	Intersectoral collaboration for people‑centred mental health care in Timor‑Leste: a mixed‑methods study using qualitative and social network analysis	Timor‑Leste	Cross-sectional study design with a mixed method SNA approach	Key stakeholders from government, NGO, civil society and other organisations working in national mental health and social care
Hoe et al. (2019)	Using social network analysis to plan, promote and monitor intersectoral collaboration for health in rural India	India	Cross-sectional study design with mixed method SNA approach	Key informants from organisations working on MCH and/or WASH in Kachhauna, Uttar Pradesh, India.
Karuga et al. (2019)	“It’s like these CHCs don’t exist, are they featured anywhere?”: Social network analysis of community health committees in a rural and urban setting in Kenya	Kenya	Cross-sectional study design with a mixed method SNA approach	Community discussants and health professionals in a rural area and an urban slum
Mukong & Burns (2020)	Social networks and antenatal care utilisation in Tanzania	Tanzania	Cross-sectional study design with quantitative SNA approach	Women aged 15–49 years.
Mulawa et al. (2016)	Evidence of social network influence on multiple HIV risk behaviors and normative beliefs among young Tanzanian men	Tanzania	Cluster-randomised HIV prevention trial with quantitative SNA approach	Urban social networks locally referred to as “camps”.
Ruducha et al., (2019)	Measuring coordination between women’s self-help groups and local health systems in rural India: A social network analysis	India	Pretest, post-test design with quantitative SNA approach	Self-help groups (SHG) members, village-level and block-level government health workers, and other key members of the community
Sabot et al., (2020)	Professional advice for primary healthcare workers in Ethiopia: A social network analysis	Ethiopia	Observational, cross-sectional study design with quantitative SNA approach	Staff at primary healthcare units
Soi et al., (2020)	Global health systems partnerships: A mixed method analysis of Mozambique’s HPV vaccine delivery network actors	Mozambique	Cross-sectional study design with a mixed-method SNA approach	Frontline Ministry of Health workers, Ministry of Education staff and supporting partner organisation members
Ssengooba, Kawooya, Namakula, & Fustukian, (2017)	Application of social network analysis in the assessment of organisation infrastructure for service delivery: A three district case study from post-conflict northern Uganda	Uganda	Cross-sectional study design with a mixed method SNA approach	District Health Offices (DHOs) and service provider organisations (SPOs)
Kawonga, Blaauw, & Fonn, (2015)	Exploring the use of social network analysis to measure communication between disease programme and district managers at sub-national level in South Africa	South Africa	Cross-sectional study design with quantitative and qualitative SNA approach	Health managers located at subnational level

Table 2. Actor networks and their definitions.

Network type	Network definition	Network description from reviewed articles
Friendship network	Close individuals who comfortably help each other on a given issue	Close friends who do not live in the same household but are comfortable to either turn to each other for advice, interest-free loan, or ask for help with harvest without paying [30].
Referral network	Relations between two or more health facilities involved in the sharing of patients from lower to higher levels of care	Networks where each referral represents a directional tie between a pair of health facilities [22].
Inter-sectoral collaboration network	Sets of organisations from different sectors which interact to achieve a particular objective	Any planning, information and resource sharing for a common purpose between organisations from different sectors and/or across thematic areas [24,29].
Partnership network	Sets of actors or agencies that formally or informally engage for a common purpose	A collaboration with the mission of accomplishing a common goal either contractually or non-contractually [27].
Community health committee networks	Group of individuals who serve as liaisons between community members and frontline health workers in the provision of health services to the community	A group of community-based committees who provide and received health-related information and are able to participate in the exchange of information and decision-making on community health services [26].
Support/supervisory networks	Two or more actors who provide support to one another based on hierarchies of the health system	A set of relationships embedded in the wider context of social and professional relationships and hierarchies within the health system [20].
Peer networks	Group or individuals with similar sociodemographic categorisation and who get along either formally, informally or both and interact on a given issue	Semiformal groups who are either friends, acquaintances, or people who get along and/or socialise regularly [19,20].
Inter-organisational network	Network formed by two or more organisations with the purpose of achieving a common goal	Relational architecture or networks among organisations to strengthening the health workforce in post-conflict northern Uganda or any linkage [support/activity/engagement] between the respondent organisation and another external organisation for strengthening health workforce [29.]
Communications networks	Communication relationship that facilitates action or decision-making among individuals or organisations	Communications involving managers through one-on-one task-related communication or communication through co-participating in management committees [22].
Professional advice networks	Individuals or group of healthcare professionals who share advice on a common issue of interest	Healthcare professionals, either having provided or sought advice for a common objective or policy of interest [28].

Table 3. Findings on networks among implementors.

Identified actor networks	Authors (Year)	Study objective	Key findings
Professional advice networks	Sabot et al., (2020)	To compare professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia	The study established that primary health care unit staff involved in the delivery of maternal and newborn health services have informal advice networks outside of supervisory structures. These advice networks of the healthcare workers in PHC units were observed to provide better change in health provider practices compared to when health care workers we-re only given training (example, in-service training) without the involvement of their networks.
Peer networks	Mukong & Burns, (2020)	To examine the impact of information externalities generated through network membership on antenatal care utilisation in Tanzania	Peer networks were seen to increase the probability of early antenatal check-up and antenatal completion. The study further found that relying on strong peer network increases the probability of antenatal completion by 23% and early antenatal initiation by 48%.
	Mulawa et al., (2016)	The study sought to evaluate the effectiveness of a camp-randomised Microfinance and health leadership intervention on sexually transmitted infections, gender-based violence and HIV risk behaviors	It was observed that peer networks of young men explained between 5.78 and 7.17% of variance in men’s normative beliefs and between 1.93 and 15.79% of variance in HIV risk behaviors
Support/supervisory networks	Assegaai & Schneider, (2019)	To identify critical actors and patterns of relationships in the supervision of ward-based outreach teams (WBOT) in a rural South African district	Support/supervisory networks were found to enable the WBOTs in drawing on sympathetic cadres identified among the PHC facility staff for support. Additionally, supervisory relationships within networks (teams) were observed to function better than those between teams and the rest of the PHC system
Friendship networks	Chami, Ahnert, Voors, & Kontoleon, (2014)	To predict health outcomes and to explain the susceptibility of a household to partake in health interventions in impoverished and under-researched developing country contexts	The findings show that friendship network helps in determining the number of ill family members, whereas the closeness of the members of the friendship network determines the individuals’ engagement in preventative health. Also was found to influence the individuals’ self-reported health status. The study further shows that the closeness between members in a friendship network predicts susceptibility to, instead of influence over, good health behaviours
Referral networks	Francetic, Tediosi, & Kuwawenaruwa, (2020)	To explore patient referral networks in two rural districts in Tanzania, Kilolo and Msalala	It was shown that referral networks facilitate the sharing of patients among health facilities
	Ruducha et al., (2019)	To assess how the health coordination and emergency referral networks between women’s self-help groups (SHGs) and local health systems have changed over the course of a 2-year learning phase of the Uttar Pradesh Community Mobilisation Project, India.	It was observed that the referral networks expanded relationships at the village level. It was established that the new relationships between the traditionally under-represented communities and local government could serve as vehicle for building social capital that could lead to a more accountable and accessible community health delivery system
Community Health Committee (CHC) networks	Karuga et al., (2019)	To explore the structure of a rural and an urban Community Health Committee (CHC) network and to analyze how health-related information flowed in these networks	CHC networks served as back-ups to government in addressing primary health care challenges by supporting Chiefs to implement government directives, such as compulsory child immunisation and discouraging banned cultural practices.
Inter-sectoral collaboration networks	Hall et al., (2019)	To investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system	Intersectoral collaboration networks facilitate information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste even in resource restricted settings. It further revealed that contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, intersectoral collaboration networks resulted in split in stewardship for mental health between subnetworks in the health and social sectors
	Hoe et al., (2019)	To understand intersectoral collaboration between the organisations working on maternal & child health (MCH) and water & sanitation (WASH) before and immediately after the implementation of the HCL Foundation (HCLF)-funded HCL Samuday Project (2015–2017) in a rural block of Uttar Pradesh state, India	Intersectoral collaboration networks enabled growth of the network of organisations working on the MCH and WASH. Additionally, intersectoral collaboration networks were able to enhance organisations’ states in serving as gatekeepers of information and also enhanced their ability to play a coordinator role
Partnership networks	Soi et al., (2020)	To examine Mozambique’s Gavi driven partnership network which delivered human papillomavirus (HPV) vaccine during the demonstration phase	Partnership networks enabled high professional trust. Also, the composition and practices of the partnership resulted in complementary relationship that engendered a favorable collaborative environment in which the best that each institution had to offer was leveraged
Communication networks	Kawonga, Blaauw, & Fonn, (2015)	To explore the use of social network analysis (SNA) to measure communication between disease programme and district managers at sub-national level in South Africa	Communication networks between the actors involved enhance the flow of information among provincial programme managers. The study further shows that communication networks facilitate complex and varied interactions, including both collaborative as well as siloed communication amongst programme and district actors
Inter-organisational networks	Ssengooba, Kawooya, Namakula, & Fustukian, (2017)	To assess the inter-organisation infrastructure that supports the provision of selected health services in the reconstruction phase after conflict in northern Uganda	Inter-organisational networks enabled organisations to exhibit a broad range of functional roles in supporting the provision of the services. It further shows that inter-organisational networks present a better opportunity for organisations to leverage for faster communication and resource flow to boost the delivery of health services

Table 4. Summary of how networks support implementation.

Networks	Authors (Year)	How networks support PHC implementation
Patient/household/community-level networks	Mukong & Burns, (2020); Mulawa et al., (2016); Chami, Ahnert, Voors, & Kontoleon, (2014); Karuga et al., (2019)	Increase the probability of early antenatal check-up and antenatal completion Ensures alignment in good behavioral practices at the community level Enables the engagement of community members in preventative health. Help in predicting the susceptibility of individuals to good health behaviours Enables local implementers such as Chiefs to implement government directives
Health facility-level networks	Sabot et al., (2020); Ruducha et al., (2019); Francetic, Tediosi, & Kuwawenaruwa, (2020); Assegaai & Schneider, (2019)	Enable the provision of better change in health provider practices Helps health workers in drawing on sympathetic cadres identified among the PHC facility staff for support Facilitate the sharing of patients among health facilities Helps in building social capital that could lead to a more accountable and accessible community health delivery system
Multi-partner networks that work across levels	Hall et al., (2019); Hoe et al., (2019); Soi et al., (2020); Kawonga, Blaauw, & Fonn, (2015); Ssengooba, Kawooya, Namakula, & Fustukian, (2017)	Facilitate information and resource sharing among organisations Enabled growth of the network of organisations serving as gatekeepers of information Enabled high professional trust among partners/stakeholders Facilitate complex and varied interactions among stakeholders Enable organisations to leverage for faster communication and resource flow to boost the delivery of health services

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